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In the three years since I have been enrolled in Medicare I have always had a Medicare Advantage Plan, with which I am well satisfied. But if that satisfaction should change in the future and I would decide to have original Medicare plus a Medigap policy, are the premiums charged for Medigap policies affected by one's age and whether one has pre-existing conditions? I know the Medicare Advantage Plans have to accept all applicants with the exception of those with end-stage kidney disease, and even for those folks there is some kind of plan available.

Are the Medigap policies similar? Does one just choose a company and a plan based on the premium for one's geographical area of residence and the features of the plan, and the plan has to accept you? Are the premiums age-related as well as benefits-related? Pre-existing conditions related?

I know this question is very basic and elementary. But I have never paid the least attention to Medigap policies once I decided to keep my doctor and my HMO with which I was already familiar and satisfied from my employer-provided health benefit prior to my turning 65. At age 65 (and with no more employer-subsidized health care) I just enrolled in that HMO's Medicare Advantage Plan and kept the same doctor, the same medical record number, and almost the same co-pays and benefits with a few minor exceptions. My navigation of their system (a large one) remained exactly the same.

Now I am having a discussion with my sister who is three years younger and I am realizing how limited my knowledge of Medicare is, in the broadest sense.

Are the Medigap policies similar? Does one just choose a company and a plan based on the premium for one's geographical area of residence and the features of the plan,

Yes. All Medigap plans must offer the same coverage. Most comprehensive is Plan F, which cover copays, excess charges, hospital deductibles, and foreign travel.

Quote:

Originally Posted by Escort Rider

and the plan has to accept you?

Yes and No.

Yes, with a waiting period for pre-existing conditions, if one enrolls at the same time one purchases Medicare Part B, or shortly thereafter.

No, if you are switching from Medigap outside the window you first become eligible. In that case, you are subject to medical underwriting, with either a waiting period for pre-existing conditions, or an outright denial of coverage. Exception is made if your current carrier is no longer covering people in your state. Then any other company has to take you and cannot impose a waiting period for preexisting conditions.

The AHCA promised protection on preexisting conditions does not apply to Advantage or Medigap. Seniors are not protected.

My sister, 62 y/o, has heart and other issues, although she is still working. She could never take an Advantage Plan. When she signs up for Medigap when she is eligible for Part B, any Medigap ins. co. must take her at that point. However, she is still subject to a waiting period on preexisting condtions - six months, I believe. Her premiums will be w/drug coverage over $200/mo, I am sure, plus the $100/mo deducted from her SS benefit. Her health issues have no bearing on her premium.

Quote:

Originally Posted by Escort Rider

Are the premiums age-related as well as benefits-related? Pre-existing conditions related?

Pre-existing conditions never affect the premium, if the company accepts you. Age very often does. You may encounter a waiting period, however, for preexisting conditions.

In WI, UHC sells community-rated policies, WPS sells attained-age rated policies. Continental Health out of Brentwood, TN has a smaller market share in WI and has substantially lower premiums for attained-age policies than either UHC or WPS.

The time to buy Medigap coverage is when you don't have health issues or, better yet if you can afford it, immediately on purchasing Part B.

I am presently on an Advantage Plan b/c my health is fine. BUT - one never knows down the road. The fixed Medigap premium for Plan F or its ilk, which covers all deductibles, copays and excess charges, is probably best for budgeting, as expenses are pretty much limited to the cost of premium. No surprises for copays, etc. Advantage can leave a substantial exposure if one is hospitalized more than once in a year, because that hospital deductible can be charged per admittance if certain parameters are not met. I've read certain facilities are categorizing outpatients as inpatients in order to improve revenue. An Advantage Plan patient could be stuck.

Plus, there is much more flexibility on who will accept your insurance with Medigap v. Advantage, which can be restrictive as to area. As Robyn continually says, Mayo accepts Medicare/Medigap. Mayo does not accept Advantage.

Ariadne, great post. Very informative. I hadn't heard much about the waiting period of 6 months for pre-existing conditions if you purchase the Gap policy when you are first eligible at age 65 or shortly thereafter (not sure of the number of months you can wait, probably no more than 6. I'd have to look it up).

Do all Gap policies have a waiting period for pre-existing conditions even if you purchase it in the "guarantee issue" period when you turn 65? I thought that only applied if you waited to purchase it later on, and as you mentioned, at that point, you would be subject to underwriting and could be denied.

Good point on the flexibility issue. Hospitals have to accept Gap plans, but don't have to take Advantage plans, which are more specific to certain hospitals and insurers. Premiums for Gap plans, which are standardized, vary greatly across the country state by state, for the exact same coverage from the same company. Further complicating the picture, different insurers will charge different premiums in the same zip code for the exact same Gap plan. Need to do a lot of research before making a decision. I looked at one insurance company and Plan F in several states and found a range of 111 to 174 per month in 2012 for a 65 year old signing up when first eligible.

Then I looked at difference insurance companies in the area where I currently live and found a wide range of premiums for the exact same Gap plan. Additionally, not all plans are offered in every state by every carrier. I think only two Gap plans are required to be offered by all carriers (not sure, but I think it's plans A & C). It's a complicated process to sort it out.

Ariadne, great post. Very informative. I hadn't heard much about the waiting period of 6 months for pre-existing conditions if you purchase the Gap policy when you are first eligible at age 65 or shortly thereafter (not sure of the number of months you can wait, probably no more than 6. I'd have to look it up).

Do all Gap policies have a waiting period for pre-existing conditions even if you purchase it in the "guarantee issue" period when you turn 65? I thought that only applied if you waited to purchase it later on, and as you mentioned, at that point, you would be subject to underwriting and could be denied.

I think the only exception would be if you had creditable coverage (i.e., employer or other insurance) before enrolling in Medicare, although this is not so stipulated in the WI handbook. So, that may be a state exception.

From Medicare.gov:

Quote:

The best time to buy a Medigap policy is during your Medigap open enrollment period. This period lasts for 6 months and begins on the first day of the month in which you’re both 65 or older and enrolled in Medicare Part B. Some states have additional open enrollment periods including those for people under 65. During this period, an insurance company can’t use medical underwriting. This means the insurance company can’t do any of the following because of your health problems:

• Refuse to sell you any Medigap policy it offers
• Charge you more for a Medigap policy than they charge someone with no health problems
• Make you wait for coverage to start (except as explained below)

While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage related to a pre-existing condition. A preexisting condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out-of-pocket costs for these pre-existing health problems for up to 6 months.

This is called a “pre-existing condition waiting period.” After 6 months, the Medigap policy will cover the pre-existing condition. Coverage for a pre-existing condition can only be excluded in a Medigap policy if the condition was treated or diagnosed within 6 months before the date the coverage starts under the Medigap policy. This is called the “look-back period.” After the 6-month pre-existing waiting period, the Medigap policy will cover the condition that was excluded. Remember, for Medicare‑covered services, Original Medicare will still cover the condition, even if the Medigap policy won’t cover your out‑of‑pocket costs, but you’re responsible for the coinsurance or copayment.

If you have a pre-existing condition and you buy a Medigap policy during your Medigap open enrollment period and you’re replacing certain kinds of health coverage that count as “creditable coverage,” it’s possible to avoid or shorten waiting periods for pre-existing conditions. Prior creditable coverage is generally any other health coverage you recently had before applying for a Medigap policy. If you have had at least 6 months of continuous prior creditable coverage, the Medigap insurance company can’t make you wait before it covers your pre-existing conditions.

There are many types of health care coverage that may count as creditable coverage for Medigap policies, but they will only count if you didn’t have a break in coverage for more than 63 days.

Talk to your Medigap insurance company. It will be able to tell you if your
previous coverage will count as creditable coverage for this purpose. You can also call your State Health Insurance Assistance Program. See pages 47–48. If you buy a Medigap policy when you have a guaranteed issue right (also called “Medigap protection”), the insurance company can’t use a pre‑existing condition waiting period. See pages 21–23 for more information about guaranteed issue rights.

Note: If you’re under 65 and have Medicare, generally because of a disability or ESRD, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law doesn’t require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you’re under 65. See page 39 for more information.

Medicare supplement insurance companies must make coverage available to you, regardless of your age, for six months beginning with the date you enroll in Medicare Part B. This six-month period is called the open-enrollment period.

Insurance companies may not deny or condition the issuance of a policy on your health status, claims experience, receipt of health care, or medical condition. The policy may still have waiting periods before preexisting health conditions are covered.

In addition, if you are under age 65 and enrolled in Medicare due to disability or end stage renal disease, you are entitled to another six-month open enrollment period upon reaching age 65/

My sister, 62 y/o, has heart and other issues, although she is still working. She could never take an Advantage Plan.

Thanks for your response, Ariadne. But I think you are wrong about Advantage Plans excluding people with pre-existing conditions (above), except for end-stage kidney disease. In my OP I confessed my near-total ignorance about Medigap policies, but I do have some familiarity with Advantage Plan by virtue of being enrolled in one. When I filled out my application for enrollment, there was nothing about health status except for end-stage kidney disease. (That is, if I recall correctly, as it's been three years ago). In fact, I was a little surprised at how short and simple the enrollment form was.

Although I need to check with Medicare on their website when I have a little more time, it wouldn't make any sense for Medicare to allow Advantage Plans to exclude people with pre-existing conditions. For one thing, by the time people are 65 there is usually some pre-existing condition or other, and the whole point of Medicare is to provide older people with medical care. If those exclusions were allowed, relatively few people would quality for Advantage Plans.

Thanks for your response, Ariadne. But I think you are wrong about Advantage Plans excluding people with pre-existing conditions (above), except for end-stage kidney disease. In my OP I confessed my near-total ignorance about Medigap policies, but I do have some familiarity with Advantage Plan by virtue of being enrolled in one. When I filled out my application for enrollment, there was nothing about health status except for end-stage kidney disease. (That is, if I recall correctly, as it's been three years ago). In fact, I was a little surprised at how short and simple the enrollment form was.

Although I need to check with Medicare on their website when I have a little more time, it wouldn't make any sense for Medicare to allow Advantage Plans to exclude people with pre-existing conditions. For one thing, by the time people are 65 there is usually some pre-existing condition or other, and the whole point of Medicare is to provide older people with medical care. If those exclusions were allowed, relatively few people would quality for Advantage Plans.

Advantage Plans can (varies by state) exclude people and/or subject them to waiting periods if one first enrolls outside the window or without previous creditable coverage or even when switching plans. When I enrolled in Advantage during open-enrollment in December 2010 (switching from an employer retiree plan costing me $1000/yr - which paid NOTHING), agent was very concerned that I had previous creditable coverage, or I would have needed to undergo medical underwriting - even during that open-enrollment period.

When I said my sister couldn't have an Advantage, I was referring to cost, not coverage.

Of course, she would be accepted in an Advantage Plan if she enrolled right way. I meant it might offer too much financial exposure for her, with copays, out-of-pocket, potential hospitalizations. We don't have your wonderful Kaiser Advantage here in WI. Advantage specialist copays here are $40 for one thing. And she sees a cardiologist, endocrinologist, and few others. She has a hard time paying for unexpected things now. Best she should budget her medical costs at whatever her Medigap/drug coverage costs will be. A good Medigap will do that. Drugs are the only variable. Here in WI, I understand Humana has a very good drug plan for about $40/mo. Most of her retired nurse friends use that.

In her case, if her Medigap w/drugs premium is $2,400/yr, she is potentially better off with Medigap as she is subject to hospitalizations and future surgery, which could cost her at least $5,000/year under Advantage in WI.

I have an elderly neighbor who was on Advantage but encountered too many copays and out-of-pocket for her budget. She was contemplating a Medigap at $230/mo which would have been an improvement. I don't know if she could have passed the underwriting at this point. Not sure if she made the switch.

Thanks for refreshing my memory about this. I will be going on Medicare in about 5 months. And I had forgotten the stuff about pre-existing conditions and creditable coverage. I am pretty sure my coverage is creditable coverage But I can't remember exactly what we we did with my husband (who had the same coverage I do). Although I seem to recall we dropped his primary coverage (which costs $500+/month) - but kept his old excess indemnity policy (which costs $150/quarter) for 6 months. There's a $10k deductible under the primary policy - and a $25k deductible on the excess - but I've met the deductible under the excess and will have excess coverage from that policy until the end of 2012. Then I would enter a new deductible period. Will have to get things straightened out when I meet with our agent sometime this summer.

One thing with regard to drug plans. If you have known medical issues - think of the most expensive drugs you might ever need as a result of those medical issues. And see if the plans you're considering cover those drugs (often called "specialty drugs"). For example - my husband could pay less on his lipitor co-pay on plans other than the one he has now. But he also has MS. Although he has never taken an expensive MS drug - he won't/can't 100% rule out the possibility down the road (don't know what his condition will be - or what new drugs will be on the market). Very few drug plans cover expensive MS drugs (they're not in their formularies). But his drug plan (AARP/UHC) does. So - instead of trying save $5 here or $10 there - look at the really big dollar stuff.

Finally - to Escort Rider - if you were to switch now or in the future - you would be subject to medical underwriting. IOW - you really can't switch if you're diagnosed with a certain kind of cancer and decide you want to be treated at MD Anderson - and Kaiser won't cover your care there. Also - your premium - at least when it comes to the kind of coverage we have - would cost you more - depending on your age. With my husband's policy - he will always be charged the rate for a 65 year old - no matter how old he gets.

OTOH - the rates for 65 year olds aren't written in stone. And when plans are discontinued - although you're entitled to keep the discontinued plan unless the insurer leaves your area - the rates for 65 year olds are kind of theoretical. For example - my father has a plan that was discontinued 20+ years ago. He is now paying about $275/month for it. It's impossible to know what it would cost if the company were to offer it to 65 year olds today.

As I have said repeatedly - I have never had any experience with Kaiser. So I can't evaluate it. I suspect it is better than the average Advantage Plan - but don't have a clue whether it is better or worse or even with traditional Medicare/Medigap when it comes to people with various medical conditions in the areas where it operates. IMO - for most people - the only reason to pick an Advantage Plan is if they can't afford traditional Medicare/Medigap when they sign up for Medicare. So if your sister can afford traditional Medicare - Plan F Medigap (best available today IMO) - and a decent part D plan - I'd tell her to go with that (unless she is also involved with Kaiser). When it comes to Medicare decisions - it is always easier to "downgrade" than "upgrade". Also - she should get a good local insurance agent who represents a bunch of companies. Won't cost her more. Although it's possible to make this a total DIY job - a good agent can save you a bunch of hours. Robyn

P.S. My husband and I were lucky (or unlucky) enough to have had some significant (or at least problematic) medical issues when we were relatively young. Many people who are mid-60ish don't think in terms of significant medical issues - because they've never faced a significant medical issue. They are just interested in saving a few dollars. Our POV is quite the opposite. We want the best possible coverage if the sh** hits the fan. And it's not like it's really expensive - at least compared to what we've been paying for medical insurance/care for the last 20 years (or compared to what a couple of expensive cell phone plans and premium cable TV channels would cost).

I think the only exception would be if you had creditable coverage (i.e., employer or other insurance) before enrolling in Medicare, although this is not so stipulated in the WI handbook. So, that may be a state exception.

From Medicare.gov:
And, from WI Guide to Health Insurance for People with Medicare:

Ariadne22, thank you for the great info in your post. You clarified the issue of pre-existing conditions and purchasing Medigap policies. Thanks too for posting all the info from the Medicare site on this topic. Very helpful!

Excellent Thread! As I turn 65 in August, I have been reading on Medicare, and it's optional parts...
much of what I have read is confusing. Asking friends whom have gone through the process brings a litany of info and opins.
This thread, and others like it on "Medicare' on in Retirement Forum on CD, are very informative. Now, to find a good cost Medigap insurer.
Just wanted to say thank you to the fine posters in this and similar threads.
BR, mD

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